Healthcare in Rural America

Rural hospitals—a vital avenue for the health of small-town communities—are overcoming challenges and keeping care close to home.

Since 2010, 83 hospitals in rural or small communities across the United States have closed, eight of which shut their doors in 2017, according to research from the University of North Carolina’s Cecil G. Sheps Center for Health Services Research. As the healthcare industry continues to change, it’s predicted that at least 700 more hospitals in rural communities are at risk of closing within the next 10 years. The American Hospital Association estimates that nearly 57 million Americans rely on the hospitals in their rural or non-urban towns for medical care. Now, many small communities are forced to make difficult decisions about the types of health services offered.

Three Solutions to Help Rural Hospitals Thrive

Many health systems are increasing their patients’ access to care by opening smaller rural health clinics, reaching out to staffing services such as HealthTrust Workforce Solutions, and introducing new delivery methods, such as 24-hour physician or nurse calls via the internet and online prescription delivery services. Here are other avenues for expanding rural healthcare.

1. Turn to telemedicine. Telemedicine can help connect rural and remote residents to specialists at larger hospitals. For example, LifePoint Health provides advanced stroke care in dozens of markets through the use of telehealth technology. Specialists located hundreds or even thousands of miles away provide expert guidance using real-time, synchronous audio and video to support the physicians caring for patients at the bedside in emergency departments. Offering telemedicine services to residents in rural communities allows them to get the care they need, saving them from having to drive hundreds of miles to meet with a specialist. Remote consultations and virtual appointments not only save time for both the patient and attending physician, but they can also cut costs for rural healthcare facili-ties that may not be able to afford full-time specialists. More important, telemedicine enables residents in rural communities to access specialized or potentially life-saving care more quickly and efficiently.

2. Adopt digital and mobile health solutions. It’s estimated that by 2021, nearly 551 million consumers will be using mobile health (mHealth) apps. This growth in mHealth technology gives hospitals and healthcare providers a greater opportunity to more easily connect with patients.
Although the future of mHealth technology is always evolving, hospitals in rural communities can benefit from early adoption. Various mHealth apps offer differing capabilities to integrate electronic health record systems, connect patients to others with similar health issues, allow physicians to provide specific educational materials, and aggregate data to communicate patient progress to both patients and providers.
Certain mHealth apps can also help with remote patient monitoring. For example, smartphone app, Kardia, is a clinically validated mobile EKG solution. It works with the supplier’s FDA-approved mobile or band ECG devices to capture a medical-grade EKG anytime. Patients can opt to send the recording to their physician or to one of the supplier’s partners for a paid clinician review by a board-certified car-diologist. This type of remote monitoring helps patients in rural communities keep track of their health and communicate with their physicians without traveling a long distance to do so.

3. Think smarter staffing. Attracting physicians and nurses to smaller communities is challenging, particularly when the pay and lifestyle of healthcare in larger cities is often more enticing, explains Brandi Vines, vice president, HCA interim leadership/locum tenens for HealthTrust Workforce Solutions. Plus, labor is one of the largest expenses in a hospital, often accounting for about 60 percent of operational costs. That’s where HealthTrust Workforce Solutions can help, Vines says. The program helps hospitals meet staffing needs while also adhering to tight budgets. For some rural facilities, hiring locum tenens is the best option.
“Hiring locum tenens helps hospitals with physician shortages and also helps alleviate physician burnout,” Vines says. “For example, the hospital may only have one orthopedic surgeon, which means that surgeon is on call 24/7. A locum tenens physician can come in for a week, a month or longer to give that physician a reprieve.”

“We help hospitals look at their staffing requirements from a holistic, birds-eye view to determine what they really need in order to meet their organizational goals,” Vines adds. “We’re consultants, not order-takers, so our focus is the success of the hospital.”

A Boost for the Community

Hospitals are cornerstone institutions for most small towns. Second only to education-related jobs, hospitals and healthcare facilities are many times the largest employers, and healthcare jobs are among some of the highest-paying and most stable positions. So, when a hospital closes, the livelihood of the town is impacted.

According to a 2017 article in JAMA, a rural hospital closing can “devastate an already stressed community through loss of healthcare workers, emergency services and primary care capacity, as well as higher unemployment and lower per-capita income, a drop in housing values, poorer health and increasing health disparities.”

Obstacles to Care

Despite their influential role in the communities they serve, hospitals in rural America face a unique set of challenges. Although uninsured rates in rural America decreased nearly 40 percent after 2010’s Affordable Care Act (ACA) went into effect, rural Americans are still more likely to live in states that have not expanded Medicaid, according to the Centers for Disease Control and Prevention (CDC). That’s unfortunate, as research shows that rural hospitals primarily rely on Medicare and Medicaid as primary payers. Researchers from the University of Colorado found that the financial performance of rural facilities improved more than the performance of suburban or urban facilities in Medicaid-expansion states, according to a January 2018 study published in Health Affairs.

However, the ACA’s Medicaid expansion isn’t the only obstacle that rural hospitals face. While the shift to value-based care has been overwhelmingly positive, it does present other challenges, says Rusty Holman, M.D., CMO of Brentwood, Tennessee-based LifePoint Health.

For example, the Centers for Medicare & Medicaid (CMS) can penalize hospitals for factors such as hospital readmissions. But, as Holman explains, the socioeconomic factors of rural communities are not considered when looking at the increase of hospital readmissions. Studies show that individuals living in non-urban areas are more likely to be older, poorer, sicker and uninsured. They also have higher injury, smoking, suicide and opioid abuse rates, according to research from the Center for Children & Families at the Georgetown University Health Policy Institute.

“We believe that social determinants of health play a significant role in patient safety, quality outcomes and transitions of care like readmissions,” Holman says.

And, of course, recruiting and retaining quality employees can be a challenge for hospital leadership in any environment. But it is often difficult to find primary care physicians or specialists who are willing to move their family to a small community or make the drive to a remote area every day. Holman says this results in a significant shortage of primary care physicians in rural communities. Nearly 20 percent of the country resides in rural areas, yet the National Rural Health Association estimates that there are only 13 primary care physicians per 10,000 people, compared to 31 physicians per the same amount of people in urban areas.

A 2014 article in The Atlantic suggests that not many people from rural communities apply for medical school. And the few that do often don’t wish to return to their hometowns after graduation. Plus, the article says, medical students become accustomed to their lifestyles while completing residencies in larger cities.

“Most residents practice where they train, but many of the nation’s prestigious medical schools are in big cities—and they are less likely to enroll rural students,” the article continues. “After eight grueling years of school and with hundreds of thousands of dollars in student loan debt, many doctors are reluctant to give up a city’s creature comforts for a more challenging existence.”

Improving Health in Rural America

At LifePoint Health, the mission is “making communities healthier,” Holman explains. For the 71 hospitals across the country that make up LifePoint’s health system, that doesn’t just mean offering free blood pressure screenings in the grocery store parking lot, but rather ensuring the health of the population and the strength of the economy and community as a whole.

“At each of our hospitals, leadership actively communicates with the local and regional chambers of commerce,” Holman says. “We also partner with public health departments to look at the broader population’s well-being and focus on community imperatives related to immunizations, preventions and screenings.”

For instance, at Clark Regional Medical Center in Winchester, Kentucky; Meadowview Regional Medical Center in Maysville, Kentucky; and Bourbon Community Hospital in Paris, Kentucky, hospital leaders work closely with the three corresponding departments of public health within its service area to focus on three strategic goals: ensuring that women of the appropriate age receive mammograms, promoting physical activity and the reduction of obesity, and addressing the opioid epidemic.

“As you can imagine, all three of those goals have a span and scope beyond the healthcare system,” Holman says. “Often, when we think about population health, we talk about formal structures such as accountable care organizations or clinically integrated networks. We certainly look within that realm, but we also think of population health as how we help serve as a leader and convener of diverse and disparate community resources to address complex health problems. As a leader in the community, our job is to identify the local resources available, organize ourselves around a common vision, and create a plan.”

Healthcare providers in rural areas are also looking at innovative ways to improve the delivery of care. The use of telemedicine and mobile health (mHealth) technology is changing the future of the healthcare industry, and research shows that in rural settings, telemedicine helps drive volume and reduce costs. According to a report in the New England Journal of Medicine, telemedicine “allows rural primary care physicians (PCPs) to potentially expand their scope of practice by obtaining specialty consults in real time. Telemedicine also potentially enables urban-based specialists to expand their patient base by caring for patients in rural or underserved areas.”

Because public transit is often non-existent and ridesharing services are limited in rural areas, telemedicine and mobile units help deliver care to individuals who may not otherwise have access to it.

The Advantages of a Health System

Rural hospitals that are part of a parent company are afforded benefits. For instance, as part of LifePoint Health, hospitals and healthcare facilities have access to subject matter experts across the country, and clinicians can benefit from peer-to-peer learning opportunities, Holman says. He recalls one story about Clinch Valley Medical Center in Richlands, Virginia: At an event to celebrate the hospital’s recent quality achievements, one department leader shared with Holman that the hospital could never have achieved the results they did without the influence and input from other hospital leaders within the broader health system.

In addition, LifePoint has been a strong advocate for rural Medicaid extenders and working with CMS to refine their approaches to quality measurement. With healthcare legislation surrounding rural hospitals in flux, it’s difficult to predict the future and plan ahead. However, when rural hospitals are part of a larger health system, they stand a better chance of success.

“We have a significant stake in supporting healthcare in rural communities,” Holman says. “Our interest is in keeping high-quality care close to home.”